Billing Based on MDM or Time

Providers may choose to base the E/M level for each patient encounter on medical decision making or total time:

Billing by Medical Decision Making (MDM)

The MDM criteria are moving away from simply adding up task and focusing instead on managing the patient’s condition. For example, you may notice that the patient’s history and physical exam are no longer elements that contribute directly to code selection, you will not be required to document a complete history every time you see the patient. However, patient history and physical exam are they are still contributing factors to managing the patient’s care, so you will need to document that you reviewed the patient’s history and document those conditions that relate directly to the patient’s present condition.

According to the AMA, medical decision making now emphasizes clinically important activities over the number of documents. There are three elements to medical decision making:

  • Number and complexity of diagnoses or treatments
  • Amount or complexity of data to be reviewed
  • Risk complications, morbidity, or mortality

There are four levels of MDM: straightforward, low, moderate, and high. For more information, go to Understanding E/M Coding Levels.

The MDM criteria are moving away from simply adding up task and focusing instead on managing the patient’s condition. For example, you may notice that the patient’s history and physical exam are no longer elements that contribute directly to code selection, you will not be required to document a complete history every time you see the patient. However, patient history and physical exam are they are still contributing factors to managing the patient’s care, so you will need to document that you reviewed the patient’s history and document those conditions that relate directly to the patient’s present condition.

Billing by Time

As an alternative to billing by MDM, you may bill based on the amount of time you spend working on an encounter. Prior to 2021, time was based strictly on the time you spend face-to-face with the patient. Beginning in 2021, time is defined as the total time spent on a given encounter. Here are some examples of activities that may contribute to time:

  • Preparing to see the patient
  • Ordering medications, test, or procedures
  • Consulting with other healthcare professionals
  • Care coordination

Activities that contribute toward time must be performed by qualified healthcare professionals on the same day as the visit. If multiple qualified healthcare professionals spend time on the encounter, that time may be added up; however, time providers spend together meeting with or discussing the patient may be counted only once. Time spent by staff may not count toward the calculation.

The following table summarizes the appropriate coding based on time. Note the difference in timeframes between new and established patients.

New Patients Established Patients
Time (minutes) Code Time (minutes) Code
— — No time set

99211 (minimal problem)

15–29

99202

 10–19

99212

30–44

99203

 20–29

99213

45–59

99204

 30–39

99214

60–74

99205

 40–54 99215

>75

99417 ×1 for each additional 15 minutes

 >55

99417 ×1 for each additional 15 minutes

Coding Prolonged Services

Prolonged services codes are used when E/M services extend beyond the total time identified with the code level that would typically be billed for the primary procedure. Less than 15 minutes is not considered prolonged.

AMA gives the following guidance for coding prolonged services.

 

Prolonged Service with Direct Patient Contact

Prolonged Service without Direct Patient Contact

Time (minutes)

Code(s)

Code(s)

<30

Not reported separately

Not reported separately

30–74

99356 ×1

99358 ×1

75–104

99356 ×1 and 99357 ×1

99358 ×1 and 99359 ×1

>105

99356 ×1 and 99357 ×2 (×1 more for each additional 30 minutes)

99358 ×1 and 99359 ×2 (×1 more for each additional 30 minutes)

Finding Additional Information

This section also includes the following topics: